Building a Better Tech Toolbox

By Rishi P. Singh, MD, Cleveland Clinic Cole Eye Institute vitreoretinal surgeon

Good features can significantly smooth the bumpy road to the adoption of a medical records system.

Adding customized, intuitive functions can improve your work flow and practice efficiency. When Cleveland Clinic’s Cole Eye Institute first made the transition to EMR, our group spent several months evaluating several systems to find just the right tools.

Even if specific capabilities weren’t initially within the system, we worked with the vendor and our IT people to create and implement those special features. These can be broken down into three distinct groups: improving the user experience of both providers and support staff; improving the billing capture and process; and integrating outcomes, administrative tasks and research activities.

Improving the user experience

Ergonomics is a key element in facilitating user adoption and acceptance of any EMR system. By incorporating the largest monitors possible, we were able to distribute a significant amount of information across a larger space. A couple key factors of the system have made it easier for physicians to adapt to the new EMR work flow:

• Hallway personal computers: We added PCs to the hallways to mimic the normal work flow where a physician reviews the chart before entering the examination or procedure room.
• Hallway printers: Placing printers in the hallway minimized the distance that physicians had to travel for printed prescriptions and patient instructions.

Drawing is a mainstay of ophthalmology practices. We have created newer pictures to represent the portions of the eye that require documentation. Creating numerous stencils for each of the drawing photos eliminates duplication of work and allows for:

• Easy annotation of the image
• Insertion of text into the same exam field of the patient
• Convenient placement of drawings within the chart
• Pulling drawings forward to a new encounter for modification
• Easy attachment of drawings to a letter to another provider

We also improved the letter-writing and documentation capabilities of our system:

• Letter templates with drop-down menus allow for quick annotation.
• An added autocorrect feature (converting common abbreviations such as OD to right eye) facilitates better communication about patients with other physicians without ophthalmic backgrounds.
• Adding the capability to fax letters directly from the EMR allows our physicians to maintain faster contact with referring providers and their staff.

Improving billing capture and process

The number of procedures and diagnostics in ophthalmology has drastically increased over the past few years. Take for example the use of intravitreal injections for eye disease. In the past five years, the number of times that procedure is done has quadrupled. Increased volume has made it difficult to track procedures and submit charges in an efficient fashion.

Our new charge-on-completion system offers:

• Improved billing compliance
• Significantly improved documentation of patient testing and procedures
• Increased efficiency in billing and reimbursement for professional fees

Here’s how it works:

• The physician places an order for the procedure or diagnostic test.
• The order generates a form for the physician to fill out.
• After the physician electronically signs the form, the charge is submitted with the specific procedural or diagnostic code to our billing team for review.
• Once reviewed electronically, the biller can submit the charge to the local carrier for processing.

This has streamlined our billing cycle from weeks to two days. It’s also decreased the potential for miscoding since it has completely eliminated manual entry. Finally, it allows for a transparent review of the indication and necessity of the procedure.

Integrating outcomes, administrative and research activities

Since 2005, all Cleveland Clinic institutes have participated in a patient outcomes reporting initiative. Until recently, the outcomes data has been compiled using manual entry and physician reporting, both ways by which reporting biases could be introduced. When we developed the entry system for our EMR, a conscious effort was made to use discrete documentation whenever possible. For example, few areas in the system have plain-text boxes for entry. Rather, buttons and checkboxes are used to document imaging, procedures and exam elements. This allows us to collect outcome metrics in an almost completely automated fashion. In addition, by using the discrete elements within our system, we created additional data streams that determine a multitude of administrative and research functions.

• Monitor supplies: We can now monitor our usage of supplies in real time to determine whether our pharmacy needs to be restocked.
• Evaluate staffing: We can evaluate the wait times by ophthalmology specialist line in an effort to maintain the proper technician-to-physician ratios.
• Optimize equipment use: Our practice has been able to monitor the frequency of use of our lasers and diagnostic modalities so we can adjust schedule templates to maximize patient flow.
• Streamline research and analysis: Research has become easier, with only a few clicks necessary to analyze multiple patient charts rather than the arduous process of chart retrieval and review.

Overall, these features have allowed for the ongoing evaluation and management of the physician and patient experience and will lead to future enhancements of both functions.